Escroto agudo en el lactante / Acute scrotum in infants

El escroto agudo consiste en un cuadro clínico de dolor testicular asociado a signos inflamatorios locales, excepcional en neonatos y lactantes. Presentamos un caso de un lactante de 2 meses con tumefacción y eritema escrotal derecho de 48 horas de evolución y pico febril en Urgencias. A la exploración, teste doloroso a la palpación, con reflejo cremastérico presente. En la ecografía testicular se objetiva orquiepididimitis derecha. La analítica muestra leucocitosis, neutrofilia y mínima elevación de reactantes de fase aguda. En el urocultivo se aísla Escherichia coli. Recibe antibioterapia durante 2 semanas con buena evolución. La orquiepididimitis es la inflamación aguda del testículo y epidídimo, patología muy infrecuente en neonatos y lactantes. La diseminación hematógena es la causa más frecuente en este grupo de edad, siendo el germen más frecuente el E. coli. Por tanto, en neonatos y lactantes con orquiepididimitis, considerando el riesgo de bacteriemia asociada, resulta fundamental optimizar el diagnóstico, incluyendo un estudio completo de sepsis junto con la ecografía Doppler y el inicio precoz de la antibioterapia empírica (AU)

Acute scrotum consists of testicular pain associated with local inflammatory signs and is very unsual in neonates and infants.We present a case of a 2-month-old infant with right scrotal swelling and erythema of 48 hours' evolution. Peak fever in the emergency department. On examination, the teste was painful on palpation, with cremasteric reflex present. Testicular ultrasound showed right orchiepididymitis with associated hydrocele. Laboratory tests show leukocytosis, neutrophilia and minimal elevation of acute phase reactants. Urine culture isolated Escherichia coli. He received antibiotherapy for 2 weeks with good evolution.Orchiepididymitis is an acute inflammation of the testicle and epididymis, and it is a very rare pathology in neonates and infants. Haematogenous dissemination is the most frequent cause in this age group, with E. coli being the most frequently isolated germ. Therefore, in neonates and infants with orchiepididymitis, considering the risk of associated bacteraemia, it is essential to optimize the diagnosis by including a complete sepsis study together with Doppler ultrasound and the early initiation of empirical antibiotherapy. (AU)

How Much Do Parents Know About Pain in Their Children?

OBJECTIVES: Adequate pain control is essential to the comprehensive management of pediatric patients within the emergency department.The aim of this study is to evaluate parents' knowledge about pain in the pediatric population patient and secondarily describe erroneous concepts that can affect a correct children's pain management. METHODS: A single-center descriptive study of cross-sectional surveys was performed between October and December 2018, with a previously validated ad hoc and anonymous questionnaire consisting of 9 items. All parents/guardians participating in the study had a child aged 0 to 18 years who had been admitted to the emergency department. RESULTS: Sixty-nine percent (n = 315) were women, 49.9% (n = 226) had university degrees and only 11% (n = 50) had professions related to the healthcare system. A linear association was observed between the number of correct answers and the level of education (ß = 1.04; 95% confidence interval, 0.76-1.32; P < 0.001), as well as between parents with professions related to the healthcare system compared with other professions (61.4% vs 51.2% with P = 0.005). The responses of Spanish parents offered better results than answers obtained from parents from the American continent (56.4% vs 41.4% with P < 0.001). No differences were observed between parents of children with chronic diseases. CONCLUSIONS: In our study, we observed that a considerable percentage of parents hold misconceptions about how children express pain, and therefore, it would be necessary to encourage formation programs for parents to help identify, evaluate, and correctly treat pain in their children.

Pain Prevalence Among Children Visiting Pediatric Emergency Departments.

OBJECTIVES: The main purpose of this study was to investigate the prevalence, characteristics, and intensity of children's pain in emergency departments. The secondary purpose was to evaluate the interobserver agreement regarding the level of pain perceived by professionals, parents, and children. METHODS: This was a multicenter, survey-based research study on 0- to 18-year-old patients visiting 1 of the 15 hospitals that form part of the Working Group on Analgesia and Sedation of the Spanish Society of Pediatric Emergency Medicine between October and December 2018. The surveys recorded pain presence, intensity, characteristics, and location. RESULTS: The study included 1216 surveys. At the time of the interview, 646 patients were experiencing pain, a prevalence of 53.1% (95% confidence interval, 50.3%-55.9%), with 25.38% reporting mild, 36.68% moderate, and 37.46% intense pain. Among the patients, 29.9% had abdominal pain and 14.1% pain in their legs.The pain lasted less than 24 hours in 48.2% of the patients, whereas only 3.0% experienced pain during more than 15 days. The parents of 50.7% of the children had provided an analgesic at home.Interrater agreement regarding pain levels was k = 0.35 between professionals and children, k = 0.38 between children and parents, and k = 0.17 between parents and professionals. For children unable to cooperate, the agreement between professional/child and the parents was k = 0.11. CONCLUSIONS: Pain is a common symptom among emergency department patients, and its evaluation should therefore be obligatory. We found low interrater agreement on pain levels between patients, professionals, and parents, which confirms how difficult it is to accurately evaluate pain intensity.

Adecuacy of pediatric antimicrobial prescribing in the Emergency Department at discharge.

INTRODUCTION: In January 2019, the Community of Madrid's Health Department published a guide about the use of antimicrobials in outpatient children. Taking this regional Guide as reference, this study was aimed at estimating the adequacy of the antimicrobial stewardship at discharge from a pediatric Emergency Department (ED). Secondarily, the differences in adequacy according to the diagnosis and the prescriber were studied, and the agreement between this Guide and the protocols of the ED was assessed. MATERIAL AND METHODS: An observational, descriptive, retrospective study was conducted on patients under 16 years old, with a diagnosis included in the regional Guide who were discharged from a pediatric ED between March of 2018 and February of 2019. Prescription was considered adequate when the indication, the antibiotic and the posology (dosage, dosing interval, length of treatment and route of administration) were correct. RESULTS: 165 out of 648 (25,5%) infectious diseases processes analyzed received antimicrobial treatment. In 23 processes treated with antimicrobial, the adequacy could not be evaluated due to the absence of data necessary to assess any aspect of posology. Therapy was considered appropriate in 550/625 processes (88.0%). When antimicrobial treatment was prescribed, 70/142 (49.3%) were appropriate and no statistically significant differences in adequacy were found between prescribers. Posology was the worst handled point of the prescription (26.3%). Tract urinary infection, conjunctivitis and otitis media were the pathologies with the lowest adecuacy (44.4%; 50.0% and 52.2%) and presented the highest discrepancy between the Guide and the center protocols (κ = 0.308; κ = 0.000; κ = 0.586). CONCLUSIONS: The adequacy of the management of infectious processes to the reference Guide in our pediatric ED was high, but it was below 50% when antimicrobial treatment was required. The degree of adequacy to the local protocols of the center was greater than to the regional Guide. This reveals a discrepancy between the 2 documents that should be analyzed and corrected according to the available scientific evidence.

Adecuación de la prescripción de antimicrobianos en procesos ambulatorios atendidos en Urgencias / Adecuacy of pediatric antimicrobial prescribing in the Emergency Department at discharge

Introducción: En enero del 2019 la Consejería de Sanidad de la Comunidad de Madrid publicó una guía acerca del uso de antimicrobianos en niños con tratamiento ambulatorio. El objetivo de este trabajo fue estimar la adecuación de la prescripción de antimicrobianos al alta desde el Servicio de Urgencias Pediátricas (SUP) en pacientes con enfermedades infecciosas, tomando como referencia esta guía regional. Secundariamente, se estudió la variación en la adecuación según el diagnóstico realizado y el facultativo prescriptor, y se valoró la concordancia entre dicha guía y los protocolos del centro. Material y métodos:Estudio observacional, descriptivo y retrospectivo en el que se incluyó a pacientes de 0-16 años con diagnóstico al alta del SUP incluido en la guía regional, entre marzo del 2018 y febrero del 2019. La prescripción se consideró adecuada cuando lo era la indicación, y en su caso, el fármaco elegido, la posología (dosis, intervalo y duración) y la vía de administración. Resultados: Se obtuvo una muestra de la que se analizaron 648 procesos infecciosos, siendo tratados con antimicrobianos 165 (25,5%). En 23 procesos no pudo evaluarse la adecuación a la guía por ausencia de algún dato posológico de la prescripción de antimicrobiano. El manejo terapéutico fue adecuado globalmente en 550/625 procesos (88,0%). En los procesos tratados con antimicrobiano, la adecuación fue de 70/142 (49,3%), sin encontrarse diferencias estadísticamente significativas entre facultativo prescriptor. El motivo de inadecuación más frecuente fue el error posológico (26,3%). Infección urinaria, conjuntivitis y otitis media aguda fueron las entidades clínicas con peor adherencia (el 44,4, el 50,0 y el 52,2% respectivamente) y en las que existió una mayor discrepancia entre guía y protocolos (κ=0,308; κ=0,000; κ=0,586). (AU)

Introduction: In January 2019, Community of Madrid's Health Department published a guide about the use of antimicrobials in outpatient children. Taking this regional Guide as reference, this study was aimed at estimating the adequacy of the antimicrobial stewardship at discharge from a pediatric Emergency Department (ED). Secondarily, the differences in adequacy according to the diagnosis and the prescriber were studied, and the agreement between this Guide and the protocols of the ED was assessed. Material and methods: An observational, descriptive, retrospective study was conducted on patients under 16 years old, with a diagnosis included in the regional Guide who were discharged from a pediatric ED between March of 2018 and February of 2019. Prescription was considered adequate when the indication, the antibiotic and the posology (dosage, dosing interval, length of treatment and route of administration) were correct. Results: 165 out of 648 (25,5%) infectious diseases processes analyzed received antimicrobial treatment. In 23 processes treated with antimicrobial, the adequacy could not be evaluated due to the absence of data necessary to assess any aspect of posology. Therapy was considered appropriate in 550/625 processes (88.0%). When antimicrobial treatment was prescribed, 70/142 (49.3%) were appropriate and no statistically significant differences in adequacy were found between prescribers. Posology was the worst handled point of the prescription (26.3%). Tract urinary infection, conjunctivitis and otitis media were the pathologies with the lowest adecuacy (44.4%; 50.0% and 52.2%) and presented the highest discrepancy between the Guide and the center protocols (k=0.308; k=0.000; k=0.586). (AU)

[Adecuacy of pediatric antimicrobial prescribing in the Emergency Department at discharge]. / Adecuación de la prescripción de antimicrobianos en procesos ambulatorios atendidos en Urgencias.

INTRODUCTION: In January 2019, Community of Madrid's Health Department published a guide about the use of antimicrobials in outpatient children. Taking this regional Guide as reference, this study was aimed at estimating the adequacy of the antimicrobial stewardship at discharge from a pediatric Emergency Department (ED). Secondarily, the differences in adequacy according to the diagnosis and the prescriber were studied, and the agreement between this Guide and the protocols of the ED was assessed. MATERIAL AND METHODS: An observational, descriptive, retrospective study was conducted on patients under 16 years old, with a diagnosis included in the regional Guide who were discharged from a pediatric ED between March of 2018 and February of 2019. Prescription was considered adequate when the indication, the antibiotic and the posology (dosage, dosing interval, length of treatment and route of administration) were correct. RESULTS: 165 out of 648 (25,5%) infectious diseases processes analyzed received antimicrobial treatment. In 23 processes treated with antimicrobial, the adequacy could not be evaluated due to the absence of data necessary to assess any aspect of posology. Therapy was considered appropriate in 550/625 processes (88.0%). When antimicrobial treatment was prescribed, 70/142 (49.3%) were appropriate and no statistically significant differences in adequacy were found between prescribers. Posology was the worst handled point of the prescription (26.3%). Tract urinary infection, conjunctivitis and otitis media were the pathologies with the lowest adecuacy (44.4%; 50.0% and 52.2%) and presented the highest discrepancy between the Guide and the center protocols (k=0.308; k=0.000; k=0.586). CONCLUSIONS: The adequacy of the management of infectious processes to the reference Guide in our pediatric ED was high, but it was below 50% when antimicrobial treatment was required. The degree of adequacy to the local protocols of the center was greater than to the regional Guide. This reveals a discrepancy between the 2documents that should be analyzed and corrected according to the available scientific evidence.

Disminuyendo el dolor en los procedimientos invasivos durante la hospitalización pediátrica: ¿ficción, realidad o realidad virtual? / Reducing the pain in invasive procedures during paediatric hospital admissions: Fiction, reality or virtual reality?

Introducción: La realización de procedimientos invasivos dolorosos con fines terapéuticos o diagnósticos en pacientes pediátricos hospitalizados es frecuente en la práctica diaria. Se deben buscar estrategias encaminadas a disminuir el dolor y la ansiedad durante estas técnicas, como el uso de realidad virtual (RV). Materiales y métodos: Se realizó un estudio observacional, analítico y prospectivo, en el cual se incluyeron todos los pacientes pediátricos hospitalizados de entre 4 y 15 años que precisaron procedimientos invasivos. Se recogieron escalas de valoración de dolor y ansiedad a los pacientes (ajustadas a su edad), familiares y personal sanitario y se comparó el uso de la RV, de manera aislada y asociado a una crema anestésica (prilocaína/lidocaína crema 2,5%), con un grupo control en el que no se utilizó ninguna técnica analgésica. Resultados: Se incluyeron 58 pacientes, de los cuales 38 usaron la RV (grupo RV) y 20 pacientes no recibieron ninguna técnica analgésica ni de distracción (grupo control). El uso de RV disminuyó las puntuaciones en la mediana de las escalas de dolor en niños, familiares y personal sanitario (grupo control 4/5 vs. grupo RV 1/5, p < 0,001), y en las escalas de ansiedad en niños (grupo control 4/5 vs. grupo RV 1/5, p = 0,001). En el análisis multivariante, el número de punciones (R2: 0,5; β: 0,6; p = 0,01) y la ausencia de técnicas coadyuvantes (β: -0,9; p = 0,02) se asociaron con puntuaciones más elevadas en la escala del dolor en niños. Comentarios: El empleo de RV disminuy:e el dolor y la ansiedad durante la realización de procedimientos invasivos en pacientes pediátricos hospitalizados

Introduction: Potentially painful invasive procedures are often performed for diagnostic or therapeutic purposes in hospitalised paediatric patients. Approaches, such as virtual reality (VR), should be sought in order to minimise pain and anxiety during these procedures. Materials and methods: Hospitalised patients between 4 and 15-years-old requiring an invasive procedure were included. Pain and anxiety evaluation scales were given to children, relatives and health workers. A comparison was made with patients in whom VR was used (with or without concomitant use of a prilocaine/ lidocaine 2.5% analgesic cream) and patients in whom neither VR nor analgesic cream were used. Results: The study included 58 patients, 38 in the VR group and 20 in the control group. Pain scores, as performed by patients, relatives and health workers, significantly decreased in the VR group (control group median 4/5 vs. VR group median 1/5, P < .001). Patient-reported anxiety scales were also lower in the VR group (control group median 4/5 vs. VR group 1/5, P = .001). The number of punctures (R2: 0.5, β: 0.6; P = .01) and the lack of analgesic techniques (β: -0.9; P = .02) were associated with higher scores in patient-reported pain scales. Comments: The use of VR can reduce pain and anxiety during invasive procedures in hospitalized children

[Reducing the pain in invasive procedures during paediatric hospital admissions: Fiction, reality or virtual reality?] / Disminuyendo el dolor en los procedimientos invasivos durante la hospitalización pediátrica: ¿ficción, realidad o realidad virtual?

INTRODUCTION: Potentially painful invasive procedures are often performed for diagnostic or therapeutic purposes in hospitalised paediatric patients. Approaches, such as virtual reality (VR), should be sought in order to minimise pain and anxiety during these procedures. MATERIALS AND METHODS: Hospitalised patients between 4 and 15-years-old requiring an invasive procedure were included. Pain and anxiety evaluation scales were given to children, relatives and health workers. A comparison was made with patients in whom VR was used (with or without concomitant use of a prilocaine/ lidocaine 2.5% analgesic cream) and patients in whom neither VR nor analgesic cream were used. RESULTS: The study included 58 patients, 38 in the VR group and 20 in the control group. Pain scores, as performed by patients, relatives and health workers, significantly decreased in the VR group (control group median 4/5 vs. VR group median 1/5, P<.001). Patient-reported anxiety scales were also lower in the VR group (control group median 4/5 vs. VR group 1/5, P=.001). The number of punctures (R2: 0.5, ß: 0.6; P=.01) and the lack of analgesic techniques (ß: -0.9; P=.02) were associated with higher scores in patient-reported pain scales. COMMENTS: The use of VR can reduce pain and anxiety during invasive procedures in hospitalized children.